Research: Triple P, Disabilities, Parent Assessments & Prevention

Did you know that children with disabilities are reported at nearly 2 times greater risk of child maltreatment than typically developing children?  Some studies indicate that children with emotional or behavior problems are at elevated risk.  Estimates of the prevalence of children 0-5 years with serious emotional/ behavioral disorders in the U.S. range from 9% to 14%.  Challenging behaviors that can have negative ripple effects on the child, family and community by disrupting parent-child relationships, increasing parental stress, isolating families and sometimes triggering child maltreatment.  Unfortunately, government -sponsored early intervention programs often don’t use evidence-based intervention programs to prevent or address these challenging behaviors.  Although research on several family-centered behavioral intervention modelshas shown positive impacts on young children with challenging behaviors and their parents, there’s a gap between research and practice in most communities.

Triple P & Children with Disabilities

The Family Networks Project: Supporting Family Confidence, Competence, and Community Connections was funded by the National Quality Improvement Center on Early Childhood to strengthen families of young children with disabilities through promotion of protective factors at the family and community level.  This project was lead by Dr. Cheri Shapiro, Associate Director of the Institute for Families in Society at the University of South Carolina to explore if Stepping Stones Triple P can prevent behavior problems for families of very young children (under 24 months) with disabilities.  The research consisted of two randomized trials to examine the impact of an evidence-based parenting intervention on parents of very young children with developmental disabilities enrolled in South Carolina IDEA Part C services.  

I am intrigued by Shapiro’s research project because it was unique and especially valuable for targeting prevention of behavior problems for families with young children with disabilities.  The study evaluated enhancing  early intervention (EI) services as usual by combining them with an evidence-based parenting program and also with enhanced professional development.  Shapiro and her colleagues have published an extensive literature review and description of the intricate details of the project’s two research studies and results in Research in Developmental Disabilities. In this blog we’ll discuss the second study that included professional development.

Stepping Stones Triple P Parenting Intervention

Stepping Stones Triple P-Positive Parenting Program (SSTP) was delivered as Level 4 of the Triple P multi-level intervention system, based on public health, community psychology and social learning theories, which has a rich history of research with a wide diversity of populations.  STTP is specifically designed for families of children with disabilities and offers 10 sessions of parent behavioral training delivered to individual families in the home.  Sessions included sharing assessments with parents, supporting positive child behaviors, managing misbehaviors, and supporting and generalizing self-selected parenting strategies and activities with their children.

Professional Development for EI Service Coordinators

Preventing Child Abuse and Neglect: Parent-Provider Partnerships (PCAN) was initially designed by Zero to Three for child care providers.  The curriculum training was adapted to enhance the capacity of IDEA Part C Service Coordinators to prevent maltreatment in very young children. PCAN training was offered to Service Coordinators in a 5-county region for this study.  PCAN focuses on the value of providers’ relationships with young children and their families, understanding risk factors related to abuse and neglect, and responding to concerning parent-child interactions. 

Families Who Participated

The 40 families who participated in the study 1) had children under 24 months of age with disabilities, 2) were enrolled in EI services and 3) were on the caseloads of EI Services coordinators who had received PCAN training.  Overall, they were mothers or grandmothers with at least 90% high school education or beyond.   Most families were Caucasian (58%), 35% were African American, and 55% were employed.  The children averaged nearly 20 months old, 68% were EI-eligible due to developmental delays and the remainder due to a diagnosis or condition showing risk of delays, such as very low birth weight.

These 40 families were randomized to form two groups:

1) Intervention group=20 (EI services as usual + STTP sessions+ providers with PCAN training)

2) Comparison group =20 (EI services as usual + providers with PCAN training). 

Child & Parent Assessments 

Child and parent assessments were conducted pre (baseline) and post intervention (5 months) and at 12-month follow-up.  Measures included parent reports of children’s social-emotional behavior, and parent self-reports of depression, anxiety, stress, parenting style and efficacy.  Parents also completed surveys about the quality of their relationships with the STTP provider and with the EI provider, as well as their satisfaction with services.  (See Shapiro’s article for specific measures). As we have mentioned in previous blogs on choosing the right tool, self-assessments can get at what parents know, think or feel.  To assess what a parent actually does requires an observational assessment. To measure the quality of parent-child interaction, this study used independent raters who were blind to families’ group status to assess parent-child play videos using the Keys to Interactive Parenting Scale (KIPS).

Assessments post-intervention and at 12-month follow-up showed no significant differences between the intervention and comparison groups in children’s social-emotional behavior.  On parent self-reports, a few statistical trends were indicated (parental depression symptoms at 5 months and parenting style at 12 months), but no significant differences were found for parenting style, self-efficacy, or mental health.  Parent-provider relationships and services satisfaction were rated highly in both groups.

Parenting Assessment Showed Significant Difference with Triple P Intervention

I was delighted to see that the KIPS results showed a trend toward higher quality parent-child relationships in the intervention group after 5 months of SSTP, and a significant difference in KIPS scores favoring the intervention group at the 12-month follow-up.  These findings resonate with the gradual upward trajectory to significance that we found in KIPS scores in our longitudinal validation study [Comfort, Gordon, English, et al. (2010)] of this tool conducted with the HANDS home visiting program in Kentucky. 

What Does this Study Mean for Research to Practice? 

 The study found no significant differences between groups in children’s behavior. The results showed trends, but no significant differences in parent’s self-reported mental health and parental functioning.  Yet assessments by independent observers with KIPS indicated that parents showed more nurturing parenting behaviors after engaging in STTP sessions combined with usual EI services and PCAN training for Service Coordinators.  Also note that the comparison group that was receiving EI services and the PCAN training showed no change in the parent-child relationship, as assessed by KIPS.  

 It is notable that the KIPS observational parenting assessment detected a significant difference in parenting, where other measures showed a trend.  As Shapiro and her colleagues concluded, there are a variety of reasons that may have contributed to the lack of significant changes in child behavior and the several self-reported parent outcomes: 

•  the young age of the children,

• the lack of existing behavior problems,

• EI Therapist and Service Coordinator support may have been sufficient,

• the wide range in disciplines of the STTP providers and/or

• the wide range in STTP content fidelity. 

We are left with many more questions for future research.  Nevertheless, the results that the KIPS observational assessment was sensitive in detecting changes in parenting behavior, shows STTP’s promise in building protective factors to prevent maltreatment for families of very young children with disabilities.  These results concur with those of a 2013 study by Carta and her colleagues with families of preschoolers at risk for child maltreatment.  Among a host of measures, they also found that parents’ behaviors, measured by KIPS, improved after a focused parenting intervention, and KIPS was the only measure that predicted children’s positive engagement in parent-child interactions. There’s a double win for practitioners in using a valid and reliable observational parenting assessment, such as KIPS. The tool can both 1) prove positive outcomes for parents and 2) provide specific information for staff to guide interventions matched to families’ needs.